Foundations for practice of the Nursing as Caring theory rest on
the nurse coming to know self as caring person in ever deepening and
broadening dimensions. While all nurses may have (or at least, may
have had) a sense of self as caring person, practicing within this
theoretical framework requires a deliberate commitment to developing
this knowledge. In many settings where nurses find themselves
practicing, there is little in the environment to support a commitment
to ongoing development of a sense of self as caring person. In fact,
many practice environments seem to support knowing self only as
instrument, self as technology. When one perceives of one's "nursing
self" as a depersonalized, disembodied tool, nursing tends to lose
its flavor and the devoted commitment to nursing burns out. So how to
sustain and actualize this fundamental commitment must be a point of
serious study for the nurse who desires to practice nursing as caring.
Mayeroff's (1971) caring ingredients are useful tools to assist the
nurse in developing an ever-present awareness of self as caring person.
Taking note of personal patterns of expressing hope, honesty, courage,
and the other ingredients is a good starting place. Understanding the
meaning of living caring in one's own life is an important base for
practicing nursing as caring. In reflecting on a particular lived
experience of caring, the nurse can seek to understand the ways in which
caring contributed freedom within the situation--freedom to be, freedom
to choose, and freedom to unfold.
Because nursing is a way of living caring in the world, the nurse can
turn his or her attention to personal patterns of nursing as expressions
of caring. As self understanding as caring person accrues, the nurse
sometimes realizes that such self-awareness was there all along--it
was only waiting to be discovered. Because many nurses were trained to
overlook their caring ways instead of attending to them, nurses may now
need something similar to, or indeed "sensitivity training" itself,
to rediscover and reown the possibilities of self as caring person,
possibilities specific to nursing as a profession and a discipline. This
redirection of focus away from caring may have been related to several
historical social movements. First, of course, is the move toward
science, which for nursing meant that for a period of several decades
nursing education seemed to reject, either partially or totally, the art
of nursing in order to discover a scientific base for practice. Another
related process, the technology movement, led nurses to understand care
as a series of sequential actions designed to accomplish a specifiable
end. In this context, nursing care became synonymous with managing
available technologies. Third, there existed in the history of nursing
education an era(s) in which nurses were taught to treat symptoms
patients expressed, rather than to care for the person. Fourth,
maintaining a professional distance was a hallmark of professionalism.
Now, and rightly so, the tide has turned. A reawakening of knowing self
as caring person becomes paramount so that the profession of nursing
returns caring to the immediacy of the nursing situation.
With personal awareness and reflection, developed knowledge of caring
also arrives through empirical, ethical, and aesthetic modes of knowing.
There is a growing body of literature in nursing that both attests
to that fact and to the process of how nurses communicate caring in
practice (e.g., Riemen, I 986a, 1986b; Knowlden, 1986; Swanson-Kauffman,
1986a, 1986b; Swanson, 1990; Kahn and Steeves, 1988). Given the various
perspectives offered by the authors just mentioned, the individual nurse
can enhance his or her ethical self-development as a caring person by
cultivating the practice of weighing the various meanings of caring
now extant in actual practice situations and then by making choices to
express caring creatively. In pursuit of this end, aesthetic knowing
often subsumes and transcends other forms of knowing and thus may
offer the richest mode of knowing caring. Appreciating structure,
form, harmony, and complementarity across a range of situated caring
expressions enhances knowing self and other as caring persons.
Knowing self as caring enhances knowing of the other as caring. Knowing
other as caring contributes to our discovery of caring self. Without
knowing the other as caring person, there can be no true nursing. Living
a commitment to nursing as caring can be a tremendous challenge when
nurses are asked to care for someone who makes it difficult to care. In
effect, it is impossible to avoid the issue of "liking" or "disliking"
the patient. Is it possible to truly care for someone if the nurse
doesn't like him or her? In this light, another question arises: How can
1 enter the world of another who repulses me? Am I expected to pretend
that this person (the patient) has not treated others inhumanely (if
that is the case)? Must I ignore the reality of the other's hatefulness
toward me (if such exists)? These are questions that come from the human
heart. They express legitimate human issues that present themselves
regularly in nursing situations.
The commitment of the nurse practicing nursing as caring is to nurture
persons living caring and growing in caring. Again, this implies
that the nurse come to know the other as caring person in the moment.
"Difficult to care" situations are those that demonstrate the extent
of knowledge and commitment needed to nurse effectively. An everyday
understanding of the meaning of caring is obviously inadequate when the
nurse is presented with someone for whom it is difficult to care. In
these extreme (though not unusual) situations, a task-oriented, non
discipline-based concept of nursing may be adequate to assure the
completion of certain treatment and surveillance techniques. Still,
in our eyes that is an insufficient response--it certainly is not the
nursing we advocate. The theory, Nursing as Caring, calls upon the
nurse to reach deep within a well-developed knowledge base that has
been structured using all available patterns of knowing, grounded in the
obligations inherent in the commitment to know persons as caring. These
patterns of knowing may include intuition, scientifically quantifiable
data emerging from research, related knowledge from a variety of
disciplines, ethical beliefs, as well as many other types of knowing.
All knowledge held by the nurse which may be relevant to understanding
the situation at hand is drawn forward and integrated into practice
in particular nursing situations. Although the degree of challenge
presented from situation to situation varies, the commitment to know
self and other as caring persons is steadfast.
Caring expressed in nursing is personal, not abstract. The caring that
is nursing cannot be expressed as an impersonal generalized stance of
good will, but must be expressed knowledgeably. That is, the caring
that is nursing must be a lived experience of caring, communicated
intentionally, and in authentic presence through a person-with-person
interconnectedness, a sense of oneness with self and other. The nurse is
not expected to be super-human, superficial, or naïve. Rather, a genuine
openness to caring and a formed intention of knowing the other as caring
person are required. In this sense, and referring back to patients with
whom an expression of empathy is problematic; liking may be understood
as a less personally committed form of caring or loving. In other words,
liking is superficial and may not require the devotion needed to know
other as caring. When the nurse truly connects with the other, liking
the other becomes a moot issue.
Stories nurses tell about their nursing bring to light the sustenance
they find in the nursing situation. Lived experiences of practice,
recounted to crystallize the essential meaning of nursing, contain the
tangible seeds of awareness of self as caring person. However, the nurse
may not be fully aware of self as caring person until the nursing
story is articulated and shared. When the practicing nurse can begin
to describe practice as the personal expression of caring with and for
another, possibilities for living nursing as caring emerge.
Here is one nurse's response to the invitation to tell a story that
conveys the beauty of nursing. The authentic presence of the nurse in
the following nursing situation focuses on honesty as an expression of
self as caring person.
HONESTY
As Jason came through the door to RAC, a young black man lying
lifelessly on a stretcher of pale green linen, the surgeon came towards
me telling me not to tell Jason that his biopsy was positive.
I felt inner terror. A man, less than 18 years old, was going to come
close to the "truth" of living today. Yet the terror inside me was
really fueled by the becoming moral issue I was going to face soon.
Jason was surely going to ask of the results upon waking from
anesthesia. "They always do." Going to sleep unknowing demands
waking-to-know. "Honesty."
Honesty as a lived precept of caring requires that I, nurse, must always
and ever regard the person nursed from a position of love. I must enter
all nursing activity with the sole purpose of using truth, only and
ever, to promote the spiritual growth of the person nursed. In this
climate of openness to myself and to the other, we can begin to
experience freedom from fear.
Jason inevitably opened his eyes only seconds or minutes later--I was so
concerned with the surgeon's directive that I lost perception of time.
My choice? The surgeon's choice? Jason's choice?
All too soon, before I could decide "how" to act, Jason had arrived at
our moment of honesty versus dishonesty.
There were tears in Jason's eyes and as quickly as the endotrachial tube
was removed, words came from Jason's essence. "Why me, God?"
I was pre-empted. (That's what happens when I write the script of
nursing.)
Instead of dancing around "telling" Jason, I was now only able to
"be-with" Jason. To suffer with Jason, to come to compassionate knowing
of Jason's subjective reality. "I heard him," Jason choked and sobbed.
I just sat next to his stretcher and held his left hand with my right
hand. I softly stroked his shoulder. This intimate hand-in-hand gesture
only expressed a small part of the instant connectedness that we were
co-experiencing, each alone, each with the other, all at once.
I sat there for more than thirty minutes telling Jason repeatedly to
rest, trust God to help him, have strength, courage, and hope.
Having come together, Jason and I, through the darkness of anesthetized
sleep to the harsh reality of "wakefulness," we both move on with our
lives.
I asked the surgeon of Jason several times, but he couldn't remember
Jason.
I will never forget Jason. Jason brought me closer to understanding
honesty as caring (Little, 1992).
An explicit realization of nursing as a personal expression of caring
can fuel a commitment to growing in caring throughout life. A vivid,
articulated sense of self connects with an equally strong and explicit
sense of nursing, and a personal commitment to caring in and through
nursing is created. Research makes the unequivocal point that those who
seek our nursing service identify caring as the sine qua non of nursing
(Samaral), 1988; Winland-Brown & Schoenhofer, 1992). Entering these
covenantal relationships obligates us to mutually live and grow in
caring. What has also become apparent through our practice is that it
is increasingly difficult for nurses to conceptualize their service
as caring. Many nurses have lost faith in themselves as persons
contributing caring in health service delivery situations. Thus, the
raison d'être for the professional service career of nursing is lost,
and nurses become disheartened.
It is our experience, as illustrated in the previous story, Honesty,
that nurses can recapture the spirit of nursing, can rekindle hope
for themselves as persons caring through and in nursing. The reader
is invited to pause a moment and experience a sense of self as person
expressing caring in nursing. You are invited to enter a quiet,
contemplative inner space. Allow the attentions and distractions of the
moment to recede as you create quietude. Now, bring to life the most
beautiful nursing you have ever done. Recall that precious instance
that stands out for you as truly nursing. Savor the fullness of that
experience. Explore the meaning of this wonderful experience of nursing.
If possible, pause now and tell the story of your finest nursing
moment--aloud to another nurse, or in writing to the nurse you are today.
Share your story and invite other nurses to share theirs with you.
Now that the moment has been reborn and communicated, it is available as
a powerful resource for you. The essence of nursing which connects you
to all others in nursing is also to be found here. In that story resides
the central meaning of nursing, available now for your inspiration and
for your study.
For many nurses, the practice of nursing as caring will require changes
in the conceptualization of nursing and nursing practice structures.
Certain ideologies and cognitive frameworks that have gained prominence
in nursing in the recent past are not fully congruent with the values
expressed in the Nursing as Caring theory.
For example, the problem-solving process introduced into nursing by
Orlando (1961), known as the Nursing Process, comes from a worldview
that is incompatible with that which undergirds nursing as caring. In
the 1960s, nurses came to value Orlando's Nursing Process for its role
in helping them organize and put to use a growing body of scientific
nursing knowledge. Having borrowed the "problematizing" approach to
service delivery that was so successful in medical contexts, the Nursing
Process also fit with an emerging documentation system known as Problem
Oriented Medical Records, which again was adapted from medicine for
nursing use. During the late 1970s and through the 1980s, this impetus
was further developed in the Nursing Diagnosis movement.
What difficulties exist with the problem-solving process in nursing?
More than anything else, this process directs nurses to locate something
in the internal or external environment or character of the client that
is in need of correction. Gadow (1984) refers to this view as a paradigm
of philanthropy. In this demeaning paradigm, "touch is a gift from one
who is whole to one who is not" (p. 68). Within the context of Orlando's
Nursing Process, such problem solving requires that the nurse find
something that needs correction to legitimately offer appropriate care.
This focus on correction--and cure--distracts nurses from their primary
mission of caring and therefore practice results in objectification,
labeling, ritualism, and non-involvement. The context for nursing is
lost.
Further, Orlando's Process has resulted in nursing's knowledge base
being ever more deeply grounded in disciplines other than nursing.
An examination of a list of nursing diagnoses reveals that specific
knowledge from disciplines such as medicine, psychology, anthropology,
sociology, and epidemiology is what is required to solve the problems
to which the diagnoses refer. Rather than leading nurses toward the
development of the knowledge of nursing, Orlando's Nursing Process has
intensified the concept of nursing as a context-free integrator of other
disciplines.
The following story of a nursing situation demonstrates the freedom and
creativity that is possible when the nurse takes a focused, unfolding
view of the lived world of nursing. What occasioned this nursing
relationship was conceptualized in the larger system as providing care
for the caregiver, providing support in a family context. Here, home
nursing is seen as once again on the ascendancy as nurses discover
what is increasingly missing in institutional bureaucratic settings--the
opportunity to nurse.
CONNECTEDNESS
I was with J. tonight, and for the first time I enjoyed "authentic
presence" with her. I am not so sure it was because I was less fatigued
and more receptive to "what is" in her home, but because J. was clearly
"different" tonight. She greeted me with her usual rush of activity and
then startled me by asking me to "be with me, please," when she gave her
son an injection and changed the injection site on his central venous
catheter line. I had met her son before, but had never been invited to
his room or the upstairs quarters. We spent a long time in A's room
with J. and A. talking, sharing thoughts and feelings about (sister) K.,
frustrations of J. trying to do it all and still find a little peaceful
time for herself, angry outbursts and feelings of shame and sadness, and
J's desire to go to Mass on Sunday without feelings of extreme anger and
despair because K. cries when J. leaves the house, and ending with J's
stated determination to do the impossible task of being all things to
all people at all times. The dialogue was really between mother and son,
with questions directed toward me but immediately answered by J. and A.
The conversation was sparkling with humor and piercing with honesty, and
created in mind's eye a rich, colorful mosaic of years of love, beauty,
and truth. Tonight I wish I were an artist so I could capture this
vision on canvas.
1. asked me to stay with A. while she did a small chore in the kitchen,
and I settled in a side chair for whatever might present itself. The
I.V. pole in the corner of the room caught my attention and A. offered
the name of the drug and its purpose. I honestly did not know that
particular drug, and had nothing to offer, so I just nodded my head.
A. looked at me, cleared his throat, and proceeded to tell me about a
problem he is encountering. I interrupted him and told him that I know
nothing about him other than his name and he is J's son, and that J.
has not shared anything about him privately with me. He smiled, and then
with his head bowed and eyes peering at me, told me that he has
AIDS, worries about the stigma, and dreads the stance most health
professionals assume when he encounters them as they interpret the name
of his disease process. I sat very still and nodded my head. I wanted to
acknowledge his pain and show acceptance of him and what appeared to be
his need to connect with me. Together we reflected on the wonderfulness
of the human spirit, the concept of personhood, and holistic beings with
thoughts, feelings, wants, and needs. When A. was ready we ventured down
the stairs and found J. sitting quietly in a rocking chair. It seemed
she had finished her "task," and I wondered how long she had been
sitting alone. I sensed that she had invited me into her private pain,
and courageously shared another part of her life with me. I also knew
intuitively that she did not want to talk about it.
J. had prepared the piano, and all of them asked me to play for them and
expressed disappointment that I did not play the piano during my visit
last week. So I played gentle, reflective songs interspersed with light
melodic phrases. Requests were offered by each member of the family,
and within minutes J. was sitting next to me on the piano bench, singing
loudly and punctuating words with feelings and strength and lending
incredible meaning to lyrics. "Old Man River," deep, low, rumbling of
the piano and purposefully driving tempo was responded to in kind with
J. stamping her food with each beat and pounding her knee with each
word as she emphatically sang "He just keeps rolling along, he keeps on
rolling along." It seemed to be cathartic for her as expressions seemed
to come from the center of her being. We applauded ourselves when we
finished and J. let me hug her. A. caught my eye and mouthed "thank
you for helping my mother to smile." J. was quiet then, and I felt her
exhaustion. We agreed that it was time to close the piano for another
week, and I left. J. followed me to my car, and left me with "God bless
you."
This was an exhausting visit to J's home, yet it was even more
energizing because of the multiple caring moments I experienced with J.
and her family. I have come to believe that caring moments are unique
to each nursing situation and evolve naturally from the mutuality of
authentic presence as the fullness of the nurse's personhood blends
with the fullness of the other's personhood. Together they transcend the
moment. The caring moment is connectedness between nurse and other and
both experience moments of joy. (Kronk, 1992)
To characterize this nursing situation with a nursing diagnosis and to
portray it as a linear process driven by the diagnosis or problem to be
addressed with a pre-envisioned outcome would be to rob the situation
of all the beauty of nursing. Because a story of a nursing situation
is narrative, there is a temporal structure. However, this structure
supports rather than destroys the "lived experience" character of the
situation. The story of the nursing situation conveys the "all-at-once"
as well as the unfolding. This approach permits us to conceptualize as
well as contextualize the knowledge of nursing the story tells. Through
story, the meaning for this nurse of knowing herself as caring person,
as entering into the world of other(s) with authentic presence, is
understood. The nurse knows other as caring person, and in that knowing
attends to specific calls for caring with unique expressions of caring
responses created in the moment.
The Nursing as Caring theory, grounded in the assumption that all
persons are caring, has as its focus a general call to nurture persons
as they live caring uniquely and grow as caring persons. The challenge
then for nursing is not to discover what is missing, weakened, or
needed in another, but to come to know the other as caring person and to
nurture that person in situation-specific, creative ways. We no longer
understand nursing as a "process," in the sense of a complex sequence of
predictable acts resulting in some predetermined desirable end product.
Nursing is, we believe, processual, in the sense that it is always
unfolding and that it is guided by intention.
Nursing is a professional service offered in social contexts, most often
in bureaucratically organized health services. Discussions of health
services, overheard in boardrooms and legislative chambers, are
languaged in impersonal, aggregate, disembodying, and perhaps more
importantly, economic terms. In contrast to the accepted ritualization
of such language, nursing has a very important role to play--to bring the
human, the personal dimension to health policy planning, and health
care delivery systems. Clearly, it is nursing knowledge itself, of human
person, of person as caring, that has been missing. While other groups
rightly bring in knowledge of efficient operation and financing,
nursing's contribution to the dialogue on effective care has the
potential to remind all players of the real bottom line, the person
being cared for. We must remember that in most industrialized countries
health service is viewed as a commodity delivery system, an economic
exchange of goods and services. While this is not the only context
for nursing, it is the most prevalent context. If nurses choose to
participate in existing delivery systems, and most do, then ways must
be created that preserve the service of nursing while responding to the
appropriate requirements of the system. Ultimately, this would require
of nurses that they become skilled in articulating their service as
nursing, and connecting that service to the recording and billing
systems in use. Although this same goal animated the nursing diagnosis
movement of the 1970s, within the terms of that movement, the result
was less than fortunate: nursing's effort to emulate the fee-for-service
billing practices of medicine failed, and nursing contributions were
neither communicated nor reimbursed.
When nurses tell the stories of their nursing situations, however, the
service of nursing becomes recognizable. The unique contribution that
nurses make, expressed in the focus of nursing, emerges across settings.
The difference between a nursing story and a typical nursing case
report is striking; the first conveys the nursing care given, the second
reports the medical-assisting activities performed by the nurse. We have
discovered in our work with nurses that while nursing care is usually
given, it is frequently neither acknowledged nor communicated.
The nurse practicing within the caring context described here will most
often be interfacing with the health care system in two ways: first,
to communicate nursing in ways that can be understood; and second, to
articulate nursing service as a unique contribution within the system in
such a way that the system itself grows to support nursing.
The concept of profession is involved in the practice of nursing as
caring. With the advent of the information and action technologies
of the twenty-first century, the present concept of professions as
repositories of esoteric knowledge employed by social elites is rapidly
becoming outdated. As many nurses will attest, the patient often teaches
the nurse about new medical technologies and about the management of
them. In this regard, what will it mean, in the next century, to profess
nursing? A renewed commitment to professional caring means that nurses
would seek connectedness in all collegial relationships as nurses are
open to discovering the unfolding meaning of human caring, with persons
valued as important in themselves. Therefore, nurses forfeit assuming
authoritative stances toward each other, the persons nursed, and other
participants in the health care enterprise. More than ever, it will mean
that nurses will, in relation with others, live out the value of caring
in everyday life. Thus, the organized nursing profession would assume
responsibility for developing and sharing knowledge of nurturing persons
living caring and growing in caring.
The following story of a nursing situation, told in the form of a
poem, exemplifies the reconceptualization called for in the practice of
Nursing as Caring. In this situation, the nurse carried out a medically
prescribed treatment, not as a form of medicine but as a form of
nursing. The nurse communicates a knowing of the other as caring person,
living courage and hope in the face of pain and fear. This example
illustrates the meaning of knowing as a caring ingredient (Mayeroff,
1971), in the connectedness of the nurse with the patient.
The nurse's knowing both forms the intention to nurse and is formed by
the intention to know other as caring person and nurture caring. A
more typical recounting of this situation would focus on the specific
procedure of the treatment being applied, in terms of the condition of
the wound. In this poem, the nurse renders the meaning of nursing.
Heating--HIV +
Your wounds weeped
Purulent with the discharge of our
Pain and fear.
They tried to hide, only to reappear.
The treatment gentle, slow
A warm, loving balm to your soul.
Your stomach was fed the comfort
Food of your youth
And your lips drank in deeply all
You knew and understood.
The memories sweetened each moment
You stood, face to face with terror of
What might be mistook.
All inside shifted as slowly it came,
A gradual awakening; embracing of pain
As you conquered your demons
A lightness appeared
To stay forever and
Abolish all fears. (Wheeler, 1990)
NURSING SERVICE ADMINISTRATION
Many of the nursing situations described in this book have taken
place in hospital settings, where the nursing service is a shared
responsibility of many nurses in a range of functional roles. Nurses
in such settings generally nurse many persons intensively and
simultaneously and share direct nursing responsibility with one or
two other nurses. How can nurses in institutional practice settings be
supported so that calls for nursing can be heard and nursing responses
made? What is the role of the nurse administrator in supporting the
practice of nurses?
It is important to understand clearly the difference between the
practice of administration which happens to be delivered by nurses
and the practice of nursing administration. Tead (1951) defines
administration as "the comprehensive effort to direct, guide, and
integrate associated human strivings which are focused toward some
specific ends or aims" (p. 3). For example, goals of administration
could be business, governmental, education, or nursing. In this
definition, it is evident that the focus must be made clear. It is not
adequate to have an understanding of administration as a role which is
focused in functions such as interpersonal, informational, and
decisional. Such a perspective ignores the value of persons and the
ministering responsibilities inherent in the role. The administrator
must connect his or her work to the direct work of nursing.
Nursing administration by name suggests a groundedness in the
discipline. The role of the nursing administrator could indeed be
questioned if the focus of the administrative practice is not nursing.
There is the assumption that the administration of nursing is practiced
from a particular conception of nursing in which the focus or goal of
nursing is clear. What the nursing administrator says and does as nurse
must reflect the uniqueness of the discipline so that nursing's unique
contributions are assured. Nursing administrators must also be able to
articulate the unique contributions of nursing to other members of the
interdisciplinary health care team.
The relationship of the nurse administrator's role to direct care is
implicit in this perspective. The nursing administrator describes him or
herself as directly involved in the care of persons. All activities of
the nursing administrator are ultimately directed to the person(s)
being nursed. It is essential that this direct connection to the goal
of nursing be made and that persons assuming nursing administration
positions be able to articulate their unique role contributions to
nursing care. Without this clarity of focus, one may be engaged in the
practice of administration but not nursing administration.
From the viewpoint of nursing as caring, the nurse administrator makes
decisions through a lens in which the focus of nursing is nurturing
persons as they live caring and grow in caring. All activities in
the practice of nursing administration are grounded in a concern for
creating, maintaining, and supporting an environment in which calls for
nursing are heard and nurturing responses are given. From this point of
view, the expectation arises that nursing administrators participate
in shaping a culture that evolves from the values articulated within
nursing as caring.
Although often perceived to be "removed" from the direct care of the
nursed, the nursing administrator is intimately involved in multiple
nursing situations simultaneously, hearing calls for nursing and
participating in responses to these calls. As calls for nursing are
known, one of the unique responses of the nursing administrator is to
directly or indirectly enter the world of the nursed, understand special
calls when they occur, and assist in securing the resources needed
by the nurse to nurture persons as they live and grow in caring. All
nursing activities should be approached with this goal in mind. Here,
the nurse administrator reflects on the obligations inherent in the role
in relation to the nursed. The presiding moral basis for determining
right action is the belief that all persons are caring. Frequently,
the nurse administrator may enter the world of the nursed through
the stories of colleagues who are assuming other roles such as
nurse manager. Policy formulation and implementation allow for the
consideration of unique situations. The nursing administrator assists
others within the organization to understand the focus of nursing and to
secure the resources necessary to achieve the goals of nursing. When the
focus of nursing can be clearly articulated, nursing's contribution
to the whole will be understood, If the focus of practice is clouded,
however, this becomes an insurmountable task. Recognition of nursing's
value is contingent upon the ability of nurses to articulate their
contribution. Traditionally, systems define contribution through patient
outcomes and other total quality measures. Future articulation of
nursing and its contributions would emanate from the values and
assumptions offered in the Nursing as Caring theory.
Sharing nursing situations with others is one way to promote the knowing
of nursing. It also is a way for other members of the organization to
see how their roles contribute to the well-being of the nursed. The
following is a nursing situation, re-presented as the poem "Last
Rights," that cries out for nursing administration, that is, nursing
support for nursing.
Last Rights
Tight faced, they found and cornered her at work
As quick as hammers pounding down a wall of
words came hard and nailed that little quirk of
honest so fast she held the rail.
"Who were you to say he was a dying man,
though he lay white, his lifethread thin.
How were you to know the speed his flying heart
would race away from bone and shin.
He was hopeless, yes, beneath that tent of
filmy gauze, but who were you to say his fate
was hinged in prayer-our magic spent.
Who knows, he might have lived another day.
"He held my hands, asked the truth," she said.
Then turned away to smooth the empty bed.
--Yelland-Marino (1993)
The nurse administrator can nurture the living in caring and growing in
caring of the person in this story by creating ways to support the
nurse at the bedside in order that the call for hope of being known and
supported as caring person, not object, can occur. What are some of
the strategies that the nurse administrator could engage in which would
reflect the nursing focus?
Because budget determination is such a prominent matter for nurse
administrators, we will begin there. Budget decisions should be directed
from the perspective of what I ought to do as nurse administrator that
would have the greatest effect on nurturing persons being cared for in
their living and growing in caring. One aspect of budget essential to
this story is time--time for the nurse to focus on knowing self and other
colleagues. As Paterson & Zderad (1988) state, for nursing practice to
be humanistic, awareness of self and others is essential. The budget
should include time allocations for staff to participate in dialogues
focused on knowing self as caring person in order that calls, such as
the one in the previous story, can be heard. The notion of dialogue is
central to transforming ways of being with others in organizations. Bohm
(1992) refers to dialogue as creating "a flow of meaning in the whole
group, out of which will emerge some new understanding, something
creative" (p. 16). Persons engaged in dialogue are focused on trying to
understand situations as perceived through another's eyes in order that
new possibilities may be recognized. Through the allocation of time,
nursing staff come to better know self and other. Shared meanings
emerge which become the "glue or cement that holds people and societies
together" (p. 16). These opportunities for knowing self assist the
nurse to achieve, as Tournier (1957) would put it, a reciprocity of
consciousness with other.
Through the opportunity to better know self as caring person, the nurse
will learn to intentionally and authentically enter nursing situations
focused on knowing and supporting the nursed as they live caring and
grow in caring. Time for reflection and collegial dialogue is necessary
to maintain this nursing lens in a period of increasing responsibility.
Such time allocation communicates the commitment of the nurse
administrator to enhance the growth of the nurse in the discipline of
nursing.
To propose that the budgeting of time is one of the most essential tasks
of a nursing administrator may seem outrageously naïve in a time
when organizations seem to be interested only in bottom-line figures.
Ironically, however, the time allocation strategy offered here supports
the goal of cost containment. Studies have shown that caring behaviors
of nurses (Duffy, 1991) and nursing staff attitudes (Cassarea et al.,
1986) are directly related to patient satisfaction. Benner and Wrubel
(1989) also found that caring is integral to expert practice. As a
result, and from the standpoint of quality of care as revenue producing,
this strategy of allowing time for dialogue and reflection has merit.
From the viewpoint of the Nursing as Caring theory, the nurse
administrators' beliefs about person would require that new ways
of being with the nursed are created and supported. The nursing
administrator models a way of being with others that portrays respect
for person as caring. Through modeling, others grow in their competency
to know and express caring. Of course creating and sustaining
environments that nurture and value the practice and study of nursing
remains the challenge facing nurses caught in the maze of various
organizational structures. Systems tend to perpetuate existing ways of
being even though their members may repeatedly question the legitimacy
of actions flowing from these structures. It is our belief that
nursing can create a culture that values caring within systems and
organizations. Systems and organizations can be reshaped and transformed
through living out the assumptions and values inherent within nursing as
caring.
Assumptions on which Nursing as Caring is built serve as stabilizers for
the organization. These assumptions directly influence the climate of
the organization and serve as the organizational pillars. The climate of
organizations is determined by beliefs and values of persons within it.
An organization grounded in the assumptions of person as described in
Chapter 1 would not support arbitrary and capricious decision making
in which the input of all persons has not been discerned. Mission
statements, goals, objectives, standards of practice, policies and
procedures emerge from assumptions, beliefs, and values that emphasize
one's humanness. If one accepts the assumption that persons are
caring by virtue of their humanness, then it follows that cultures are
comprised of caring persons. Respect for person as person is engendered
within this context. There is a desire to know and support the living of
caring; to support each other in being who we are as caring persons in
the moment. Therefore, assumptions of Nursing as Caring ground not only
the theory but may likewise influence the ontology of the organization
itself.
Generally, organizational structures reflect bureaucratic values.
Structures imply ways of being with and relating to people. The process
of relating is typically illustrated in a hierarchical fashion. The
concept of hierarchy carries with it the notion that there is a
"top" and a "bottom." Competition, levels, and positions of power
are implicit. In climbing the rungs of a bureaucratic ladder, it is
difficult for the employee to be authentic and valued as a unique person
with special ideas because the risks of such valuing are often too great
for the bureaucracy to bear. Competition too remains the driving force
of most organizations.
Within an organization, however, we can imagine each person's hands as
clinging to the rungs of the bureaucratic ladder. Taken further, this
image would clearly portray persons who are not and can not be open to
receive and know other. Because of the vertical axis of the bureaucratic
hierarchy, persons, more often than not, are viewed as objects. The
ladder positions people so that they are either looking up or down but
rarely eye-to-eye. Obviously, the hierarchical model does not support
the idea of each person as important in and to him or herself.
By contrast, and from the assumptions posited in Nursing as Caring, the
model for being in relationships resembles a dance of caring persons
(Boykin, 1990). The same persons are present in this circle that were in
the hierarchical structure described above. The difference between the
two models is the philosophical way of being with other. Because the
nature of relating in the circle is grounded in a respect for and
valuing of each person, the way of being is diametrically opposed to
traditional patterns of relating in organizations. Leaving the security
provided by known hierarchical structures, however, requires courage,
trust, and humility. Building on the assumptions of this theory, one can
infer that the basic dance of all persons in relationships is to know
self and other as caring person. Each person is encouraged and supported
in a culture that values person-as-person, person as caring.
[Illustration: Dancing Circle]
The image of a dancing circle is also used to describe being for and
being with the nursed. In the circle, all persons are committed to
knowing self and other as living and growing in caring. Each dancer
makes a distinct contribution because of the role assumed. The dancers
in the circle do not necessarily connect by holding hands although they
may. Each dancer moves within this dance as called forth by the nature
of the nursing situation. The nursed calls for services of particular
dancers at various points in time. Each person is in this circle because
of their unique contribution to the person being cared for ... nurses,
administrators, human resources, etc. These roles would not exist if it
were not for the nursed. There is always room for another person to join
the dance. Rather than the vertical view described earlier, this model
fosters knowing other. Eye-to-eye contact assists one to know and
appreciate each other as caring persons. Each person is viewed as
special and caring. No one person's role is more or less important than
the other's. Each role is essential in contributing to the process of
living grounded in caring. As each person authentically expresses their
commitment in being there for and with the nursed, caring relationships
are lived. When the focus in any health care institution fails to be
the person cared-for, purpose, roles, and responsibilities become
depersonalized and bureaucratic rather than person-centered and caring.
Personal knowing--knowing of self and other--is integral to the
connectedness of persons in this dance. The nursing administrator
interfaces with persons of many disciplines as well as with the nursed.
With each interaction, the nurse administrator is honest and authentic
in encouraging others to know and live out who they are. Each encounter
with another is an opportunity for knowing other as caring person.
From an organizational standpoint the nursing administrator assists
in creating a community that appreciates, nurtures, and supports each
person as they live and grow in caring moment to moment. The nursing
administrator assists nurses to hear and understand the unique calls for
nursing and supports and sustains their nurturing response.
REFERENCES
Benner, P, & Wrubel, J. (1989). The primacy of caring: Stress and coping in health in illness. CA: Addison-Wesley.
Bohm, D. (1992). On dialogue. Noetic Sciences Review, pp. 16-18.
Boykin, A. (1990). Creating a caring environment: Moral obligations in the role of dean. In M. Leininger & J. Watson (Eds.), The caring imperative in education. New York: National League for Nursing, pp. 247-254.
Cassarrea, K., Millis, J., & Plant, M. (1986). Improving service through patient surveys in a multihospital organization. Hospital and Health Services Administration, 31 (2), 41-52.
Duffy, J. (1992). The impact of nurse caring on patient outcomes. In Gaut, D. (Ed.). The
presence of caring in nursing. New York: National League for Nursing, pp. 113-136. Gadow, S. (1984). Touch and technology: Two paradigms of patient care. Journal of Reli-
gion and Health, 23,63-69.
Kahn, D., & Steeves, R. (1988). Caring and practice: Construction of the nurse's world. Scholarly Inquiry for Nursing Practice, 2 (3), 201-215.
Knowlden, V. (1986). The meaning of caring in the nursing role. Dissertation Abstracts International, 46 (9), 2574-A.
Kronk, P. (1992). Connectedness: A concept for nursing. Unpublished manuscript.
Little, D. (1992). Nurse as moral agent. Paper presented at University of South Florida Year of Discovery Seminar, Sept. 1992.
Mayeroff, M. (1971). On caring. New York: Harper & Row.
Orlando, I (1961). The dynamic nurse-patient relationship. New York: G.P. Putnam's Sons. Paterson, J., & Zderad, L. (1988). Humanistic nursing. New York: National League for Nursing.
Riemen, D. (1986a). Noncaring and caring in the clinical setting: Patients' descriptions. Topics in Clinical Nursing, 8,30-36.
Riemen, D. (1986b). The essential structure of a caring interaction: doing phenomenology. In P. Munhall & C. Oiler (Eds.). Nursing research: A qualitative perspective. Norwalk, CT: Appleton-Century-Crofts.
Roach, S. (1987). The human act of caring. Ottawa: Canadian Hospital Association. Samarel, N. (1988). Caring for life and death: Nursing in a hospital-based hospice. Dissertation Abstracts International, 48 (9), 2607-B.
Swanson-Kauffman, K. (1986a). Caring in the instance of unexpected early pregnancy loss. Topics in Clinical Nursing, 8,37-46.
Swanson-Kauffman, K. (1986b). A combined qualitative methodology for nursing research. Advances in Nursing Science, 8,58-69.
Swanson, K. (1990). Providing care in the NICU: Sometimes an act of love. Advances in
Nursing Science, 13 (1), 60-73.
Tead, 0. (1951). The art of administration. New York: McGraw-Hill.
Tournier, P. (1957). The meaning of persons. New York: Harper & Row.
Wheeler, L. (1990). Healing-HIV+. Nightingale Songs, P.O. Box 057563, West Palm Beach,
FL 33405-7563, 1 (2).
Winland-Brown, J., & Schoenhofer, S. (1992). Unpublished research data. Yelland-Marino, T. (1993). Last rights. Nightingale Songs, P.O. Box 057563, West Palm Beach, FL 33405-7563, 3 (1).
[Illustration: Button]
CHAPTER V. -- IMPLICATIONS FOR NURSING EDUCATION
In this chapter, we address the implications of our theory for nursing
education, including designing, implementing, and administering a
program of study. The assumptions that ground Nursing as Caring
also ground the practice of nursing education and nursing education
administration. The structure and practices of the education program
are expressions of the discipline and, therefore, should be explicit
reflections of the values and assumptions inherent in the statement of
focus of the discipline. From the perspective of Nursing as Caring, all
structures and activities should reflect the fundamental assumption that
persons are caring by virtue of their humanness. Other assumptions and
values reflected in the education program include: knowing the person as
whole and complete in the moment and living caring uniquely; understand
that personhood is a process of living grounded in caring and is
enhanced through participation in nurturing relationships with caring
others; and, finally, affirming nursing as a discipline and profession.
The curriculum, the foundation of the education program, asserts the
focus and domain of nursing as nurturing persons living caring and
growing in caring. All activities of the program of study are directed
toward developing, organizing, and communicating nursing knowledge, that
is, knowledge of nurturing persons living caring and growing in caring.
The model for organizational design of nursing education is analogous
to the dancing circle described earlier. Members of the circle include
administrators, faculty, colleagues, students, staff, community, and the
nursed. What this circle represents is the commitment of each dancer to
understanding and supporting the study of the discipline of nursing. The
role of administrator in the circle is more clearly understood when the
origin of the word is reflected upon. The term administrator is derived
from the Latin ad ministrare, to serve (Guralnik, 1976). This definition
connotes the idea of rendering service. Administrators within the circle
are by nature of role obligated to ministering, to securing and to
providing resources needed by faculty, students, and staff to meet
program objectives. Faculty, students, and administrators dance together
in the study of nursing. Faculty support an environment that values
the uniqueness of each person and sustains each person's unique way
of living and growing in caring. This process requires trust, hope,
courage, and patience. Because the purpose of nursing education is to
study the discipline and practice of nursing, the nursed must be in the
circle. The community created is that of persons living caring in the
moment, each person valued as special and unique.
We have said in Chapter 1 that the domain of a discipline is that which
its members assert. The statement of focus that directs the study of
nursing from this theoretical perspective is that of nurturing persons
as they live caring and grow in caring. The study of nursing is
approached through the use of nursing situations. The knowledge of
nursing resides in the nursing situation and is brought to life through
study. The nursing situation is a shared lived experience in which the
caring between the nurse and the one nursed enhances personhood or the
process of living grounded in caring. These situations, like the many
cited in earlier chapters, become available for study through the use of
story (recounting the situation in ways that convey the essence of the
lived experience). These stories create anew the lived experience of
caring between the nurse and the nursed, and bring to life the basic
values described in Chapter 1.
Story then becomes the method for studying and knowing nursing. Carper's
(1978) four patterns of knowing serve as an organizing framework for
asking epistemological questions of caring in nursing. Those patterns
include personal, ethical, empirical, and aesthetic knowing. Each of
these patterns comes into play as one strives to understand the whole of
the situation. Personal knowing centers on knowing and encountering self
and other, empirical knowing addresses the science of caring in nursing,
ethical knowing focuses on what "ought to be" in nursing situations,
and aesthetic knowing is the integration and synthesis of all knowing
as lived in a particular situation. The poem, "Intensive Care," a
representation of a nursing situation, is given here to illustrate the
organization of sample content.
INTENSIVE CARE
(centered)
Did you see nurse that you can know me--
The part that is me, my mind and soul is in my eyes
These tubes that are everywhere-that is not me.
The one in my throat is the worse of all--
Now my whole being, the essence of me I
must reflect
through my hands but they are tied down,
movements
of my head but did you realize that
uncomfortable for me
or through my eyes and you do not notice them--
except once today during my bath.
You speak to me and look at the tubes--
Don't you know my thoughts are all over my face
Don't you realize your thoughts are on your face--
In your touch and your tone of voice.
I wrote a request on paper and you said "I'll take care
Of it for you" your tone said "Why can't this
woman
Do anything for herself?"
You positioned your hand to count my pulse but I
Can't say you touched me-you wouldn't hold my
hand that I may touch you.
You walked in for the first time today with a grin
on your face but your mouth is now tight
you grimaced a lot as you bathed me.
Don't you see nurse that you can know me--I'm not
A chart or tubes of medication, monitors or all
the other things you look at so intensely--I'm
more than that
I'm scared--just look in my eyes.
--S. Carr, 1991
Carper's (1978) patterns of knowing offer a framework for organizing the
content for studying this nursing situation.
PERSONAL KNOWING
Who are the nurse and nursed as caring persons in the moment?
How are the nurse and nursed expressing caring in this moment?
What is the meaning of this situation to the nurse and nursed in
terms of present realities and future possibilities?
What is the meaning of vulnerability and mortality?
What is the value of intuition in practice?
Empirical Knowing
What nursing and related research exists on modes of communication,
the meaning of presence in practice, touch, objectification,
recovery of cardiac patients, technological caring,
understanding the experience of fear and loneliness?
What factual knowledge is needed to be competent in this particular
situation--e.g. knowledge of monitors, chest tubes,
medications, cardiac care, diagnostic data?
ETHICAL KNOWING
If nursing is practiced from the perspective of Nursing as Caring,
what obligations are inherent in this situation?
How is the nurse demonstrating the value that all persons are caring?
Respect for person-as-person? Interconnectedness?
What dilemmas are present in this story?
AESTHETIC KNOWING
How is the nursed supported to live dreams of living and growing in caring?
How could the nurse transcend the moment to create possibilities
within this specific nursing situation?
What metaphors might express the meaning of this nursing situation?
Students studying this nursing situation are challenged to know the
person as caring, as living caring uniquely in the moment, as having
hopes and dreams for growing in caring, and as being whole or complete
in the moment. The student is also challenged to know the nurse as
caring person in the moment and to project ways of supporting the nurse
as caring person.
Through the study of this situation, students and faculty identify
a range of calls for nursing as well as nurturing responses. In this
process, there is dialogue focused on knowing the nurse and nursed in
the story as caring person. We would contribute the following as our
knowing of the nursed as caring person. Through her honest expression of
"I'm scared--just look in my eyes," we know her as living hope, honesty,
and transcending fear through courage.
Calls for nursing might include a call to be known as caring person and
a call to have interconnectedness recognized and affirmed. The nurse's
response to these calls is individual and evolves from who one is as
person and nurse. Therefore, the range of responses is multiple and
varied--each reflecting the nurse's informed living of caring in the
moment. Each nurturing response is focused on nurturing the person as
he or she lives caring and expresses hopes and dreams for growing in
caring.
If the nurse is responding to the call of the person for recognition
and affirmation of interconnectedness, perhaps the nurse would express
hearing this call by being present with the intention of knowing
other as caring person. This may be communicated through active
patience--giving the other time and space to be known; through touch
which communicates respect and interconnectedness; through the nurse
sharing who he or she is as caring person in this relationship--perhaps
through tears as the resonance of commonality of this experience is
known; through music or poetry if a shared love of these has been
discovered.
Through dialogue, students and faculty openly engage in the study of
nursing. The dialogue encourages and supports students and faculty to
freely express who they are as person and nurse living caring through
the re-presented story. It provides an opportunity to affirm values
of self and discipline and to study how these values may be lived in
practice. It is in this dialogue of nursing that faculty communicate
their love for nursing. Time is needed for both faculty and students
to reflect on the meaning of being a member of this discipline and more
specifically, on the meaning of being a member of a discipline
focused on nurturing persons as they live and grow in caring. Dialogue
facilitates the integration of this understanding and is a key concept
in present and future transformations of nursing education. Common
engagement in dialogue as nursing stories are shared and studied is the
way of being.
The story lived anew provides students the opportunity to participate
in a lived experience of nursing and to create new possibilities. Since
nursing can only occur through intentionality and authentic presence
with the nursed, students and faculty share how they prepare to enter
the world of the nursed, and how they come to understand that world.
This process requires that students be encouraged to live fully their
personhood. To facilitate such living, faculty support an environment in
which students are free to choose and to express self in various ways.
For example, perhaps the holistic understanding of a nursing situation
would be expressed as aesthetic knowing through dance, poetry, music,
painting, or the like. We view this process of education as critical to
moral education. When students enter nursing situations to know other as
living and growing in caring, they are living out the moral obligation
that arises from the commitment to know person as caring. Here, then,
is an expression of a dynamic view of morality in which caring is always
lived in the moment.
In the study of the situation, Intensive Care, brought to the dialogue
are personal experiences of being alone, being afraid, and being with
someone and not being heard or seen as caring person. This
personal knowing fosters human awareness of our connectedness and
interdependence. In this context, the nurse does not study the empirics
of cardiac pathology to understand a perceived deficit but rather to
become competent in drawing forth the knowledge that is specific to
knowing this person as whole in the moment. The nurse comes to know
the person as living caring and growing in caring, situated within
a particular set of circumstances, some of which the nurse knows
explicitly. Each student entering the nursing situation will ask,
"How can I nurture this person in living and growing in caring in
this situation?" Because each nurse may hear calls for caring in many
different ways, nursing responses are many and varied. For nursing
faculty, openness to multiple possibilities presents a particular
challenge and an opportunity to suspend entrenched patterns of teaching
nursing.
Faculty and students study nursing together. Faculty join students in a
constant search to discover the content and meaning of the discipline.
Undoubtedly, this understanding of extant possibilities presents a
different view of the role of teacher. Yet, it is a view that engenders
the sort of humility essential to nursing for there is always more
to know. Although past methods of teaching of nursing may have been
comfortably structured through textbooks organized around medical
science, faculty are now empowered to question what should be the focus
of study in the discipline of nursing. Faculty are encouraged to take
risks and let go of the familiar. The perspective that Nursing as Caring
conveys--the fullness and richness of nursing--will allow faculty to
willingly assume the risks inherent in a new way of guiding the study of
nursing.
In teaching Nursing as Caring, faculty assist students to come to know,
appreciate, and celebrate self and other as caring person. Mayeroff's
On Caring (1971) provides a context for the generic knowing of self as
caring. Through dyads or small groups, students share life situations
in which they experienced knowing self and other as caring person.
Mayeroff's caring ingredients (knowing, alternating rhythm, trust,
honesty, hope, courage, humility, patience) also serve as a source for
reflection as one asks "who am I as caring person?". As students engage
in this exercise, their emerging reflections begin to ground them as
they grow in their understanding of person as they live and grow in
caring. Students will also draw on the knowledge gleaned in the study
of arts and humanities as they attempt to gain a deeper understanding of
person. The process of knowing self and other as caring is lifelong. In
an educational program grounded in Nursing as Caring, however, the focus
on personal knowing (in the study for every nursing situation) provides
a deliberate opportunity for greater knowing of self and other as caring
person.
Students, as well as faculty, are in a continual search to discover
greater meaning of caring as uniquely expressed in nursing; journaling
is an approach that facilitates this search. For example, in a special
form of journaling, students actively dialogue with authors whose works
they are reading and with the ideas expressed in their works. This
process enhances the students' understanding of caring in nursing.
Over time, students integrate and synthesize many ideas and create new
understandings. Examination is another process to facilitate learning.
From this theoretical perspective, essay examinations that present
nursing situations provide opportunities for students to express their
knowledge of nurturing persons living and growing in caring. Aesthetic
projects also allow the student the opportunity to communicate
understanding of a nursing situation. We would like to share with you
a project from a course in which the students were asked to express the
beauty of a nursing situation. In this nursing situation, the nurse,
Michelle, shared her gifts of therapeutic touch and voice as expressions
of caring for David in the moment, drawing on an earlier dialogue in
which David told her of his love of meditation and the Ave Maria, she
wrote:
AVE MARIA
AND THERAPEUTIC TOUCH
FOR DAVID
"David, let me know your pain;
From fractured leg and heart,
Share with me your private hell.
Next to one who's far,
Far away his own world:
Moaning, crying, weak.
What's it like to lie beside
One who cannot speak?
"Tell me David, what you do
To cancel out the sound;
Eliminate the smell of dung
In which your roommate's found?
Who can you complain about?
Are you worse off than he?
Tied to IV, traction lines
You cannot be free.
"David, I can see your pain.
Tell me where you are.
Tied in bed. Powerless.
From loved ones you're apart.
I can't move you from this place
To take your pain away.
But let me lay my hands on you
And sing to you today."
Ave Marie, gratia plena
Maria, gratia plena.
Ave dominus, dominus tecum.
Benedicta to in mulieribus.
Et benedictus
Et benedictus, fructus ventris;
Ventris tui, Jesu.
Ave Maria
I sang the song he loved and used
To meditate and flee,
Escape tormenting stimuli.
He needed to be freed,
To understand why he must bear
This trial, this hell, this pain,
I sang the tune; I touched with care
To give him peace again.
--Stobie, 1991
Expressions of nursing such as this, which was partly sung, beautifully
portray the living of caring between the nurse and the nursed and
exemplify how caring enhances personhood. Faculty play a vital role in
fostering in students the courage to take such risks. Faculty encourage
self-affirmation in students, open, nonjudgmental dialogue, living the
caring ideal in the classroom and development of the students' moral
groundedness in caring (Boykin & Schoenhofer, 1990). Faculty also take
the risk of sharing self through their stories of nursing. The sharing
of nursing situations is, in essence, a sharing of our innermost core
of common identity and forms a type of collegiality among those who are
studying the discipline together.
How can faculty be supported to teach nursing in new ways? The
administrator of the program fosters a culture in which the study of
the discipline from the caring perspective, as presented here, can be
achieved freely and fully. All actions of the dean are directed toward
creating, maintaining, and supporting this goal. The theoretical
assumptions ground the activities of the dean in both internal and
external areas of responsibility.
Internally, the administrator, faculty, staff, and students model
commitment by creating an environment that fosters the knowing, living,
and growing of persons in caring. The dean "ministers" by assuring that
faculty, students, and staff are presented ongoing opportunities to
know themselves ontologically as caring persons and professionals and
to understand how caring orders their lives. Who we are as person
influences who we are as student, colleague, nurse, scholar, and
administrator. Therefore, attention must be directed to knowing self.
Time must be devoted to knowing and experiencing our humanness.
The constant struggle to know self and other as caring person nourishes
our knowing of the nursed. Through constant discovery of self, the other
is also continually discovered. This culture sensitizes each person
to ways of being with other that necessitate that each action reflect
respect for person as person. Therefore, when issues are to be
addressed, they are addressed openly and fully. Persons are encouraged
to bring forth who they are so there is congruence between actions and
feelings. Understanding each other's views is essential to the unfolding
of this culture. Dialogue assists one to know the other's needs and
desires, and to image oneself in the other's place. As such, the dean,
faculty, staff, and students become skilled in the use of the caring
ingredients, internalized as personally valid ways of expressing caring:
knowing, alternating rhythms, trust, hope, courage, honesty, humility,
and patience (Mayeroff, 1971).